| DEPRESSION | OPINION cosmetic changes from psychometric
raters, participants wore an opaque surgical cap, which covered the glabella and forehead during examinations. The study concluded — for the first
time — that a single botulinum treatment of the glabellar region with BOTOX could reduce the symptoms of major depression. This effect developed within a few weeks and persisted until the end of the 16-week follow-up period. The effect sizes in the study were large and the response and remission rates high. It is still unknown how botulinum toxin actually reduces depression and it is postulated that a number of mechanisms may be involved. As a result of the clinical data relating to botulinum toxin treatment on emotional perception, it is assumed that reduced proprioceptive feedback from the paralysed facial muscles is a relevant mechanism of mood improvement. As the authors did not include patients
who were cosmetically concerned about their frown lines, it is unreasonable to assume that an aesthetic benefit was the major cause of mood improvement. There is a small possibility of either placebo effect or central pharmacological botulinum toxin effects, including possible pharmacodynamics or pharmacokinetic interactions with concomitant antidepressant therapy.
The ‘Botox Paradox’ So, who is correct? Does Botox reduce or augment depression? How can the findings of Dr Lewis be in complete contrast to those of other researchers? I believe that both are correct, and that the
answer to tise apparent medical paradox lies with the original theories of Darwin. Dr Lewis and colleagues found that
people treated for another muscle (around the crows’ feet) left patients feeling more depressed. This does not contravene Darwin’s original hypotheses; in fact it supports it. The muscles around the eye are related to happiness and smiling, and to restrict their movement must interfere with the facial feedback hypotheses in a converse way to those in the glabellar area. We can only assume that reduced proprioceptive feedback from these paralysed facial muscles is a relevant mechanism of mood deterioration, and this is why they may increase depression. Accordingly, happiness can make you smile and smiling can make you happy. It is obvious that the facial musculature not only expresses, but also regulates, mood states. Botulinum toxin injection interferes with the ‘facial feedback hypothesis’ originally postulated by Darwin. (Perhaps it was my sixth sense, but I never felt right about totally removing crow’s feet around a patient’s eyes.)
Conclusions There is growing evidence that botulinum toxin injection to the glabellar region may be an effective, safe, and sustainable intervention in the treatment of depression. The reason for this has not yet been fully evaluated, but we must consider the concept that the facial musculature not only expresses, but also regulates, mood states. Owing to the longer intervals between treatments, it
References
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3. Heckmann M, Teichmann B, Schröder U, Sprengelmeyer R, Ceballos-Baumann AO. Pharmacologic denervation of frown muscles enhances baseline expression of happiness and decreases baseline expression of anger, sadness, and fear. J Am Acad Dermatol 2003; 49(2): 213–6
4. Larsen RJ, Kasimatis M, Frey K. Facilitating the furrowed brow: an unobtrusive test of the facial feedback hypothesis applied to unpleasant affect. Cognition Emotion 1992; 6: 321–38
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Castrop F, Ceballos-Baumann AO, Wohlschläger AM, Haslinger B. The link between facial feedback and neural activity within central circuitries of emotion--new insights from botulinum toxin-induced denervation of frown muscles. Cereb Cortex 2009; 19(3):537–42
6. Havas DA, Glenberg AM, Gutowski KA, Lucarelli MJ, Davidson RJ. Cosmetic use of botulinum toxin-a affects processing of emotional language. Psychol Sci 2010; 21(7): 895–900
7. Neal DT, Chartrand TL. Embodied emotion perception: amplifying and dampening facial feedback modulates emotion perception accuracy. Soc Psychol Personal Sci 2011; doi: 10.1177/1948550611406138
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may also be an economic option, and the safety and tolerability record of botulinum toxin injections to the glabellar region is excellent. However, further studies are required,
including focus on muscles in the lower sections of the face. It is possible that treatment of the depressor angularis oris and the mentalis muscles, for example, may also have mood-elevating effects, and may enhance the clinical effect of the glabellar injection of botulinum toxin. Modulation of mood states with
botulinum toxin may also be effective in the treatment of other clinical conditions involving negative emotions, like anxiety disorders. There have also been recent studies investigating the possibility of botulinum toxin for bipolar disorder and post-traumatic stress disorder (PTSD). It is paramount to remember that
botulinum toxin to the glabellar region may be an effective, safe, and sustainable intervention in the treatment of depression. The reason for this has not yet been fully evaluated, but we must consider the concept as depression affects a huge number of people, making it one of the leading causes of disability worldwide.
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